Skip to main content

Advertisement

SpringerLink
Log in

Assessment of DIEP Flap Perfusion with Intraoperative Indocyanine Green Fluorescence Imaging in Vasopressor-Dominated Hemodynamic Support Versus Liberal Fluid Administration: A Randomized Controlled Trial With Breast Cancer Patients

  • Reconstructive Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Dogmatic denial of vasopressor agents for blood pressure regulation during free-flap surgery is associated with concomitant large-volume intraoperative fluid administration. Yet, the doctrinal banning of vasopressors during microvascular breast reconstruction still is a subject of controversy. Several retrospective observations have recently drawn attention to serious iatrogenic consequences of intravenous crystalloid overload in microsurgery such as thrombus formation and increased flap failure rates.

Methods

This prospective randomized controlled trial investigated the potential effects of fluid-restrictive vasopressor-dominated hemodynamic support (FRV) compared with vasopressor-restrictive liberal fluid administration (LFA) on clinically relevant perfusion of the deep inferior epigastric perforator (DIEP) flap via intraoperative indocyanine green (ICG) fluorescence imaging. The primary end point of the study was quantitative assessment of the percentage of insufficiently perfused tissue (NP) on the overall flap. Major complications were assessed as secondary end points.

Results

In 44 DIEP flap breast reconstructions after mastectomy, FRV circulatory support resulted in no statistically significant difference in total flap perfusion as detected via ICG fluorescence imaging in direct comparison with a traditional LFA strategy (NPFRV, 31.8% ± 12.2% vs NPLFA, 29.5% ± 13.3%; p = 0.559). One flap failure was registered with LFA, whereas no major complication occurred in the FRV cohort.

Conclusions

According to the results of this study, neither a norepinephrine concentration of 0.065 ± 0.020 μg/kg/min (FRV) nor fluid administration of 5.1 ± 2.2 ml/kg/h (LFA) has a clinically significant impact on microperfusion in a standard DIEP flap procedure for breast reconstruction. Consistent with the current literature reporting a rise in complications with intraoperative fluid over-resuscitation, one flap failure occurred in the LFA cohort.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Sigurdsson GH, Thomson D. Anaesthesia and microvascular surgery: clinical practice and research. Eur J Anaesthesiol. 1995;12:101–22.

    CAS  PubMed  Google Scholar 

  2. Hagau N, Longrois D. Anesthesia for free vascularized tissue transfer. Microsurgery. 2009;29:161–7.

    Article  Google Scholar 

  3. Massey MF, Gupta DK. The effects of systemic phenylephrine and epinephrine on pedicle artery and microvascular perfusion in a pig model of myoadipocutaneous rotational flaps. Plast Reconstr Surg. 2007;120:1289–99.

    Article  CAS  Google Scholar 

  4. Szabo Eltorai A, Huang CC, Lu JT, Ogura A, Caterson SA, Orgill DP. Selective intraoperative vasopressor use is not associated with increased risk of DIEP flap complications. Plast Reconstr Surg. 2017;140:70e–7e.

    Article  CAS  Google Scholar 

  5. Hong JPJ, Suh HSP. Discussion: selective intraoperative vasopressor use is not associated with increased risk of DIEP flap complications. Plast Reconstr Surg. 2017;140:78e–9e.

    Article  CAS  Google Scholar 

  6. Ibrahim AM, Kim PS, Rabie AN, Lee BT, Lin SJ. Vasopressors and reconstructive flap perfusion: a review of the literature comparing the effects of various pharmacologic agents. Ann Plast Surg. 2014;73:245–8.

    Article  CAS  Google Scholar 

  7. Pattani KM, Byrne P, Boahene K, Richmon J. What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope. 2010;120:717–23.

    Article  Google Scholar 

  8. Chen C, Nguyen MD, Bar-Meir E, et al. Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction. Ann Plast Surg. 2010;65:28–31.

    Article  CAS  Google Scholar 

  9. Zhong T, Neinstein R, Massey C, et al. Intravenous fluid infusion rate in microsurgical breast reconstruction: important lessons learned from 354 free flaps. Plast Reconstr Surg. 2011;128:1153–60.

    Article  CAS  Google Scholar 

  10. Motakef S, Mountziaris PM, Ismail IK, Agag RL, Patel A. Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg. 2015;135:290–9.

    Article  CAS  Google Scholar 

  11. Haughey BH, Wilson E, Kluwe L, et al. Free flap reconstruction of the head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg. 2001;125:10–17.

    Article  CAS  Google Scholar 

  12. Clark JR, McCluskey SA, Hall F, et al. Predictors of morbidity following free-flap reconstruction for cancer of the head and neck. Head Neck. 2007;29:1090–101.

    Article  Google Scholar 

  13. Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012;114:640–51.

    Article  Google Scholar 

  14. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology. 2005;103:25–32.

    Article  Google Scholar 

  15. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238:641–8.

    Article  Google Scholar 

  16. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32–8.

    Article  CAS  Google Scholar 

  17. Anker AM, Prantl L, Strauss C, et al. Vasopressor support vs liberal fluid administration in deep inferior epigastric perforator (DIEP) free-flap breast reconstruction: a randomized controlled trial. Clin Hemorheol Microcirc. 2018;69:37–44.

    Article  CAS  Google Scholar 

  18. Holm C, Mayr M, Hofter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg. 2006;117:37–43.

    Article  CAS  Google Scholar 

  19. Giunta RE, Holzbach T, Taskov C, et al. Prediction of flap necrosis with laser induced indocyanine green fluorescence in a rat model. Br J Plast Surg. 2005;58:695–701.

    Article  CAS  Google Scholar 

  20. Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg. 2012;129:1043–8.

    Article  CAS  Google Scholar 

  21. Temple-Oberle C, Shea-Budgell MA, Tan M, et al. Consensus review of optimal perioperative care in breast reconstruction: enhanced recovery after surgery (ERAS) society recommendations. Plast Reconstr Surg. 2017;139:1056e–71e.

    Article  CAS  Google Scholar 

  22. Wong C, Saint-Cyr M, Mojallal A, et al. Perforasomes of the DIEP flap: vascular anatomy of the lateral versus medial row perforators and clinical implications. Plast Reconstr Surg. 2010;125:772–82.

    Article  CAS  Google Scholar 

  23. Diep GK, Hui JY, Marmor S, et al. Postmastectomy reconstruction outcomes after intraoperative evaluation with indocyanine green angiography versus clinical assessment. Ann Surg Oncol. 2016;23:4080–5.

    Article  Google Scholar 

  24. Wang WZ, Anderson G, Firrell JC. Arteriole constriction following ischemia in denervated skeletal muscle. J Reconstr Microsurg. 1995;11:99–106.

    Article  CAS  Google Scholar 

  25. Lorenzetti F, Suominen S, Tukiainen E, et al. Evaluation of blood flow in free microvascular flaps. J Reconstr Microsurg. 2001;17:163–7.

    Article  CAS  Google Scholar 

  26. Eley KA, Young JD, Watt-Smith SR. Power spectral analysis of the effects of epinephrine, norepinephrine, dobutamine, and dopexamine on microcirculation following free tissue transfer. Microsurgery. 2013;33:275–81.

    Article  Google Scholar 

  27. Eley KA, Young JD, Watt-Smith SR. Epinephrine, norepinephrine, dobutamine, and dopexamine effects on free-flap skin blood flow. Plast Reconstr Surg. 2012;130:564–70.

    Article  CAS  Google Scholar 

  28. Kelly DA, Reynolds M, Crantford C, Pestana IA. Impact of intraoperative vasopressor use in free tissue transfer for head, neck, and extremity reconstruction. Ann Plast Surg. 2014;72:S135–8.

    Article  CAS  Google Scholar 

  29. Harris L, Goldstein D, Hofer S, Gilbert R. Impact of vasopressors on outcomes in head and neck free tissue transfer. Microsurgery. 2012;32:15–9.

    Article  Google Scholar 

  30. Feldheiser A, Aziz O, Baldini G, et al. Enhanced recovery after surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand. 2016;60:289–334.

    Article  CAS  Google Scholar 

  31. Hendrix RJ, Damle A, Williams C, et al. Restrictive intraoperative fluid therapy is associated with decreased morbidity and length of stay following hyperthermic intraperitoneal chemoperfusion. Ann Surg Oncol. 2019;26:490–6.

    Article  Google Scholar 

  32. Ettinger KS, Arce K, Lohse CM, et al. Higher perioperative fluid administration is associated with increased rates of complications following head and neck microvascular reconstruction with fibular free flaps. Microsurgery. 2017;37:128–36.

    Article  Google Scholar 

  33. Patel RS, McCluskey SA, Goldstein DP, et al. Clinicopathologic and therapeutic risk factors for perioperative complications and prolonged hospital stay in free-flap reconstruction of the head and neck. Head Neck. 2010;32:1345–53.

    Article  Google Scholar 

  34. Fang L, Liu J, Yu C, Hanasono MM, Zheng G, Yu P. Intraoperative use of vasopressors does not increase the risk of free-flap compromise and failure in cancer patients. Ann Surg. 2018;268:379–84.

    Article  Google Scholar 

  35. Wade RG, Razzano S, Sassoon EM, Haywood RM, Ali RS, Figus A. Complications in DIEP flap breast reconstruction after mastectomy for breast cancer: a prospective cohort study comparing unilateral versus bilateral reconstructions. Ann Surg Oncol. 2017;24:1465–74.

    Article  Google Scholar 

  36. Pashikanti L, Von Ah D. Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature. Clin Nurse Spec. 2012;26:87–94.

    Article  Google Scholar 

  37. Gocze I, Jauch D, Gotz M, et al. Biomarker-guided intervention to prevent acute kidney injury after major surgery: the prospective randomized BigpAK study. Ann Surg. 2018;267:1013–20.

    Article  Google Scholar 

  38. Perazella MA. Onco-nephrology: renal toxicities of chemotherapeutic agents. Clin J Am Soc Nephrol. 2012;7:1713–21.

    Article  CAS  Google Scholar 

  39. Succar L, Pianta TJ, Davidson T, Pickering JW, Endre ZH. Subclinical chronic kidney disease modifies the diagnosis of experimental acute kidney injury. Kidney Int. 2017;92:680–92.

    Article  Google Scholar 

  40. Futier E, Lefrant JY, Guinot PG, et al. Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery: a randomized clinical trial. JAMA. 2017;318:1346–57.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Center for Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Regensburg and Caritas Hospital St. Josef Regensburg, Regensburg, Germany

    Alexandra M. Anker MD, Lukas Prantl MD, Catharina Strauss MD, Vanessa Brébant MD & Silvan M. Klein MD

  2. Department of Anesthesiology, Caritas Hospital St. Josef Regensburg, Regensburg, Germany

    Felix Schenkhoff MD & Michael Pawlik MD

  3. Department of Clinical Cancer Prevention and The McCombs Institute for the Early Detection and Treatment of Cancer, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Jody Vykoukal MD

Authors
  1. Alexandra M. Anker MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lukas Prantl MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Catharina Strauss MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Vanessa Brébant MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Felix Schenkhoff MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michael Pawlik MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jody Vykoukal MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Silvan M. Klein MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alexandra M. Anker MD.

Ethics declarations

Conflict of interest

There are no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (MP4 1009 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Anker, A.M., Prantl, L., Strauss, C. et al. Assessment of DIEP Flap Perfusion with Intraoperative Indocyanine Green Fluorescence Imaging in Vasopressor-Dominated Hemodynamic Support Versus Liberal Fluid Administration: A Randomized Controlled Trial With Breast Cancer Patients. Ann Surg Oncol 27, 399–406 (2020). https://doi.org/10.1245/s10434-019-07758-1

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-019-07758-1

Search

Navigation